Letting the mothers die, silently

“My mother died while giving birth to my brother, Ehsaan,” said Nabila with tears in her eyes. “She had severe anemia and other health issues induced by multiple pregnancies and lack of adequate nutrition,” she added. Doctors had told their father they could either save the mother or the child. Her father was desperate to save his wife, who took care of his two little daughters. In spite of doctors’ efforts she breathed her last as soon as Ehsaan was born. The child remained sick for a month before finally recovering.Nabila’s mother earlier had three children, who died shortly after birth, and two surviving daughters, including her. Now married and herself a mother of three children, Nabila said, “If my mother had proper counselling and access to contraceptives, her life could have been saved.” In areas with no access to family planning services, women sometime bear 12 or more children. Population welfare remains one of the most neglected areas in Pakistan. July 11 was celebrated the world over as the World Population Day. Still, the tragedy that around 14,000 mothers die annually in Pakistan due to complications during pregnancy and childbirth (source UNFPA) did not make headline news.According to Dr Narmeen Hamid, a leading reproductive health adviser in Pakistan, “Women’s health is not a priority for their families, community or for political parties, who make policies.” Pakistan has committed to reduce maternal mortality by 75 percent between 1990 and 2015, and provide universal access to maternal health by 2015 to meet UN’s Millennium Development Goal five. Latest indicators suggest it will miss the target.According to Pakistan Millennium Development Goals Report 2010 (Planning Commission, government of Pakistan), maternal mortality in Pakistan stands at 276 per 100,000 live births, while the target to meet MDGs is 140. The proportion of births attended by skilled birth attendants is 40 percent; the target stands at more than 90 percent. The contraceptive prevalence rate is 29.6 percent, whereas the target is 55 percent. The total fertility rate is 4.1 births per woman, targeting for 2.1.Several research studies have revealed that the story of Nabila’s mother is very common in the rural areas of Pakistan, regardless of geographical location. Illiteracy, low status of women, malnutrition, poor health facilities and, most of all, failure of the government to provide a range of good quality contraceptives and counselling are causing mothers and neonates to die. Even in big cities like Lahore, government hospitals cannot cope with the burden of patients that swarm the city from all over the province.A visit to Kot Khwaja Saeed Teaching Hospital confirmed this fact. The hospital is located in a densely populated area of Lahore near Shad Bagh. There was barely enough space for everyone to sit as women waited for their turn at the outdoor unit of the gynaecology department. Pregnant women waited for hours to get the ultrasound exam done. When the wait time increases, women are discouraged and leave. Despite inadequate facilities, women who receive some form of consultation regarding their health are among the lucky ones. As one moves out of big cities, government medical facilities are few and far between.A research report titled Rising to the Challenge: An analysis of the implementation of MDG-5 in Pakistan found that reproductive health facilities are located at an average distance of 12 kilometres in rural areas. The government has consistently given importance to maternal health in its 5-year plans over past decades. However, its focus has been misplaced, as enough attention was not paid to family planning as a tool for maintaining good maternal health. According to Dr Saman Yazdani, director of Center for Population Studies, “The government has always been focused on population control. This was a wrong approach. Family planning must be linked to maternal health because space between children is necessary not only for the mother and child’s health but for the overall wellbeing of the family. Due to lack of access to contraceptives, abortion has become the primary method of family planning in Pakistan,” she added.With low prevalence of contraceptive use, unsafe abortions are widespread, sometimes leading to dire consequences. The doctor at Kot Khwaja Saeed Hospital told me that she receives many cases of ruptured uterus, severe infection and other complications caused by unsafe abortions where it is difficult to save women’s lives. “If these women had access to proper counselling and quality contraceptives, their lives could be saved,” she said.According to the report Unwanted Pregnancy and Post-Abortion Complications in Pakistan (Population Council, 2004), some 890,000 unwanted pregnancies end in induced abortion each year in Pakistan. Around 80 percent of women who go for abortion have three or more living children. Unsafe abortions account for 13 percent of maternal deaths, while 197,000 women are treated annually for post-abortion complications in public sector facilities and private teaching hospitals. This number must be higher because it excludes women who never go to a doctor to treat these complications.In these circumstances, even if the government pours billions of rupees in the health sector to prevent maternal deaths, mothers will continue to die. Hence there is need for robust family planning programmes in all four provinces, led by Population Welfare Departments (PWDs). PWDs have the requisite expertise and experience to procure contraceptives, run clinics and train staff to provide counselling on this sensitive issue to both husband and wife. This kind of counselling cannot be provided by the overburdened doctors at government hospitals.Provincial PWDs worked under the Federal Ministry of Population Welfare under a unified vision of the federal government. After the passage of the 18th Amendment, this division was devolved to provinces in 2010. In the absence of outspoken advocates for family planning within political parties, competing priorities have taken precedence in the provinces’ calculus of development.In Punjab, it took almost three years for the government to start the process of devising the population welfare policy. Started in January this year, it is expected to be finalised in a couple of months with inputs from various stakeholders. Despite being a more developed province with a substantial budget, Punjab’s PWD is still dependent on the Federal Ministry of Population Welfare for funding of its programmes. The contraceptives procurement is being financed through a USAID project, which will conclude in September this year. In addition, there is a severe shortage of trained staff in Punjab PWD. Out of 350 vacancies for doctors, only a 100 are working. Another 110 vacancies of theatre nurses are also lying vacant. The employee turnover is very high because most jobs are low-paid and contract based. Whenever a contract employee finds a better opportunity, she leaves her job PWD on a short notice. In the process, the department loses millions spent on training its staff, and allocating more resources for training newcomers.Dr Aaisha Qureish, Deputy Secretary at the Punjab PWD has been with the department for the last 22 years. She said, “It is important to give highly skilled staff such as doctors and nurses incentives at par with the health department, so that they remain committed and make a career with us.” She informed that doctors working with the health department are being offered Rs 60,000 per month as well as additional allowances, whereas doctors working on contract with PWD only get paid Rs 30,000 per month. This disparity weakens PWD’s efficacy in hiring and retaining skilled staff.Investing in PWD also makes economic sense. Space between pregnancies implies better maternal health, fewer, healthier children, and less economic burden on the family, community and government services. A relatively small investment in this department can go a long way in making real difference in the lives of millions of families and saving government a lot of expenses in areas such a health, development, education, etc.